ADMISSION PROCEDURE

(LORMA MEDICAL
CENTER)
 Receiving Patient

• Admit patient according to admission

procedure
• Position comfortably on bed with side rails up.
• Change patient’s dress into hospital gown
 Taking Vital Signs
Take the vital signs and record them in the Special
Charting, Graphic Chart, and Admission
Record/History and Physical Examination

• Blood Pressure
• Temperature
• Cardiac Rate
• Pulse Rate
• Respiratory Rate
• Oxygen Saturation
- Administer Oxygen right away via face mask if
oxygen saturation is below 90%
 Gathering Patient’s Information
Obtain the following data from the patient relative
and note them down in the Admission/History
and PE, and Therapeutic Sheet:
• Data of Patient
• Complete Medical History
• AMD
• Allergies to food and drugs
 Examination
Conduct examination and record findings in the
Admission Record/History and PE, POMR Sheet
(Problem-Oriented Medical Record) and
Consultation/Referral Sheet
• Check for airway, breathing and circulation
• Physical examination
– Skin
– Pupils
– Chest, head, neck, back
– Abdomen-lower and upper
– Extremities-lower and upper
• Neurological Examination – level of
consciousness using Glasgow Coma Scale
 Carrying out Doctor’s Order
Carry out doctor’s orders written in the
Physician’s Order Sheet. Record procedures
performed/ orders carried out in the POMR.
There are patients with order from their AMD
already; either have them copied by ROD into
Physician’s Order Sheet.
• Prepare IV Fluids to be inserted and place IV tags
properly.
• Insert IVF, collect blood sample for laboratory
examination.
• Administer emergency drugs and make requests
for other examinations
• Administer medicines prescribed/ordered.
– Request for laboratory exams if ordered (forward
Laboratory request form to the laboratory) or enter through
Computer Medsys.
– Request for X-ray exams if ordered (forward an X-ray
request form to the Radiology Department) or enter
through Computer Medsys.
– Request for ECG if ordered (forward an ECG request form
to the ECG section).
– Request for CT Scan, ultrasound, MRI, echocardiogram if
ordered (Notify the department by phone) or through
Computer Medsys. And prepare patient before procedure.
 Notification
Notify the following as indicated in the
Physician’s Order-Sheet and POMR:
• Notify Admitting Staff-on-duty about patients
admission. Notification
• Notify ROD to admit/examine patient.
• Notify laboratory department for blood
extraction.
• Notify AMD about the vital signs and
condition of the patient.
• Notify Medical Specialist if referral by AMD.
• If patient is scheduled for operation, notify
Surgeon on duty, Anesthesiologist, and
Operating Room (OR) forward notice of
operation to OR.
• Notify Supervisor on duty and PNP for
Medico-legal cases
• Dietary department for patient’s diet.
• NOD or Nurse Aide if the room of choice of
the patient is ready
 SOAPIE CHARTING

Write date and time patient arrived, condition of

patient upon admission and what medical
procedures have done to the patient in the
POMR.
Complete the necessary data needed for charting;
• Graphic chart
• Special charting
• Therapeutic sheet
• IV Fluid and Blood Transfusion Sheet
• Summary and Checklist of Charges
• Physician’s Order Sheet
• Problem-Oriented Progress Notes (POMR)
• Admission Record/History and PE
Accompany patient to his/her room with
contraptions intact and place the graphic chart
on the foot part of the bed.
Endorse patient to the Nurse on duty giving
emphasis on what has been done to her/him at
the ER (Emergency Room)
Place door card and directory card.
Make the necessary changes in the Computer
(Medsys. Program) Refer to summary and
checklist of charges.
Make ER charges
Make Nursing Service charges
Make Respiratory charges
Encode patient’s data and impression in the
computer.
Write patient’s data and impression in the
Admission record book
Get medicines from pharmacy to replace used
stocks.
Get stocks from CSR to replace the used ones.
THANK YOU FOR LISTENING!